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  • Hormone Therapy

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    Old 07-08-2019, 02:54 PM   #1
    Join Date: Jul 2019
    Location: Atlanta, GA
    Posts: 1
    evansk HB User
    Hormone Therapy

    radiation/seeds in 2009; cryo in 2018; now hormones; into 4th month.
    PSA is undetectable for two months.

    What should be my expectation.
    How many months of zero PSA gets you off the therapy for a while and what is a usual time between ending and starting a new series of hormone shots.
    I realize it depends on PSA, but just looking to get an idea of what to expect.


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    Old 07-09-2019, 09:03 AM   #2
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    Join Date: Nov 2007
    Location: Annandale, VA, USA
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    IADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB User
    Re: Hormone Therapy

    Hi evansk and welcome to the Board!

    You have asked very good questions that matter to many prostate cancer patients and their loved ones.

    I am real familiar with this territory as I had to make these calls for myself in the early 2000s before we had some of the helpful data that we now have. That also means I have seen some changes in recommendations. However, there are still no hard and fast rules for a standard of care that I know of; different experts have their own approaches, and individual patient circumstances make a difference. (I am a now savvy patient who was on ADT from late 1999 through 2014, which became ADT3 in the fall of 2000 and intermittent in 2002. I have apparently been cured by radiation in 2013, supported by 18 months of my final course of ADT3. Such repeated long spans of IADT are likely no longer necessary for some patients because of advances in imaging that enable finding and targeting the remaining pockets of cancer, thereby stopping the recurrence.)

    “Undetectable” is a term that has varied meanings for PSA, basically linked to the lower value of the PSA test version being used. Some doctors still order PSA tests with a lower limit of just less than (<) .1 ng/mL, which to me is not adequate. What is needed is a test below that level, generally referred to as “ultrasensitive,” and that seems to be the standard of good care. Different versions of ultrasensitive PSA tests also have different lower limits of reliable detection, such as <0.05, <0.04, <0.01 and <0.001. My impression is that it is best, when your PSA is <0.1, to use a test with sensitivity down to <0.01; an even more sensitive test might be helpful, but I am unaware of research showing that such tests provide information that makes a clinical difference, which to us patients means a difference that will give us a benefit. Do you know exactly what your PSA score was, such as <0.1, <0.05, <0.01, etc.? This will make a difference in managing trigger points to go on and off vacations from intermittent ADT.

    My impression is that doctors I consider leaders would like a patient’s PSA to be <0.01 before going on a vacation from ADT. However, I believe they would find it acceptable to go on vacation if a patient got their PSA to any value <0.05. Doctors differ on this, and in some clinical trials of intermittent ADT the vacation trigger has been much higher, even as high as a PSA of 4 (see below). If it were me making this decision with what I now understand and believe, I would wait until my PSA was <0.01 or until it leveled out below 0.05. However, I am among the patients who is able to put up with the side effects, minimized by countermeasures, fairly well. If I were among those patients who were having a rough time with ADT and could barely wait to get off it, I would lean toward a higher trigger point, provided cancer control appeared good. You can probably see how this is a bit of a balancing act. My impression is that it is good to stay on ADT – no vacation – if you have metastases that are detectable by the old technetium bone scan or CT scan, of if you cannot get your PSA below 0.05, but it is clear there is debate about this in the medical community of informed, experienced doctors. (If you have mets detected only by advanced scans, IADT would probably be okay, depending on the evidence.)

    Back in 2001 and 2002 when I was making this call for myself, the doctors who were pioneers in IADT and especially IADT3 were recommending that their patients get their PSA down to <0.05 and successfully maintain it there for a year before going on vacation. That’s what I did. It took me a long time because I had an aggressive case and my initial PSA was over 100. Most patients will get their PSAs below 0.05 within eight months, with some in just a few months, which might be you. Now, and for many years, the consensus of those pioneers seems to me to be that it is sufficient to just get your PSA down to <0.05 or <0.01 if possible without needing to keep it there for a year before commencing the vacation. However, at least one practice I follow closely is convinced there is a benefit from staying on ADT for longer than just a few months. I suspect they would want their patients on ADT for at least 8 or 9 months even if their PSAs were <0.01. Some doctors would probably want a longer period, perhaps a year or a bit more, but likely not longer than 18 months.

    The length of the vacation time is variable. For me, even with my challenging case, I was on vacation for more time than I was on therapy (34 months for my first vacation after 31 months on ADT3), but I had supportive therapy to boost the vacation time. One of the boosters is a drug in the 5-alpha reducatase inhibitor class, either finasteride (Proscar) or dutasteride (Avodart). I did that and am convinced it helped, but that tactic is not widely accepted. You might want to look into it. I was also on a more profound type of ADT, ADT3 (initially Lupron plus Casodex plus Proscar) during my on-therapy time, and that likely also lengthened my vacation time; on the other hand, the challenging nature of my cancer probably decreased my vacation time.

    Here are links to a couple of papers on intermittent therapy. The first reviews several trials of IADT and has a link to a free copy of the complete paper: . It is loaded with information and considerations about your concerns, and has references that you can pursue also. The second paper,, is about IADT after patients who had recurred after radiation, which is your situation. It too has a link to the complete paper with lots of useful information and references. Figure 2 and the section headed “Treatment Phase Dynamics” describe the vacation durations for patients who were under the treatment rules of this trial. The average first vacation lasted 20.1 months, the second for 13.2 months, the third for 9.1 months, and subsequent vacations for declining durations of from 4 to 5 months, with declining numbers of patients enjoying more than one vacation (58% a second vacation, 32% a third, and so on).

    However, I am convinced that modern technology, including the use of finasteride or dutasteride, would substantially improve these figures. Keep in mind that the length of the vacation partly depends on how profoundly you reduce the cancer, judged by PSA, and how soon you choose to end the vacation. In this latter trial, they used an 8 month treatment cycle and then put the patient on vacation when his PSA was <4 and did not exceed 1 ng/mL higher than the previous recorded value as monitored in that treatment cycle. In my view, this was too early to commence the vacation, but most patients would have been far below that PSA by the end of the 8th month. With modern technology, the success levels should be higher.

    As these papers show, the triggers to restart therapy vary, but are often about 10, with some even allowing up to a PSA of 20 (which I think is far too high for most patients, though I used that myself in special circumstances for me in my third cycle vacation, looking forward to my fourth cycle supporting radiation). The experts I follow, who have an abundance of experience over decades with ADT, believe that for most patients ADT should be restarted when the PSA hits between 3 and 6 (following initiation of vacation after a PSA hopefully at least as low as <0.05). They like the lower value if the patient has a shorter PSA doubling time (PSADT) on vacation (after the initial recovery of testosterone), and the higher value if the PSADT is longer. However, individual considerations, such as tolerance of the side-effects of ADT and the aggressiveness of the recurrence, affect this. For instance, my doctors and I were happy with a trigger point of about 10 to resume therapy because my initial PSA had been so high and because I clearly responded to ADT very well, getting down to low points of <0.01.

    Just a final note, have you considered advanced highly sensitive imaging to try to spot and wipe out the spots where the cancer has recurred? That strategy is increasingly being used.

    Good luck!

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